Explosives Employee Possessor Questionnaire

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OMB No. 1140-0072

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Explosives Employee Possessor Questionnaire

EACH EMPLOYEE POSSESSOR MUST COMPLETE AND SIGN A SEPARATE QUESTIONNAIRE - ATF FORM 5400.28. In the future, 		
if you need to add an additional Employee Possessor (EP) to your Federal Explosives License or Permit (FEL/P), the EP being added must complete a
new ATF Form 5400.28. A Responsible Person (RP) must submit a signed written request along with a completed ATF Form 5400.28, granting
permission to add a new EP to an existing FEL/P.
List any given, married, and maiden names in Item 4 (e.g., “Mary Alice (Smith) Jones,” not “Mrs. John Jones.”). (If additional space is needed, attach a
separate sheet. See Instruction 1.)
1. Federal Explosives Licensee or Permittee Name

2. Federal Explosives License or Permit Number (If being added to an existing FEL/P)

3. Name of Employee Possessor (Last, First, Middle)
6. Social Security Number (Voluntary)

4. Aliases (Include given, married, maiden names, etc.) 5. Position/Title

7. Date of Birth (MM/DD/YYYY) 8. Place of Birth (City & State OR Foreign Country)

9. Current Full Residential Address

11. Telephone Number (Including area code)

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10. Mailing Address (If different from residential address)

14. Previous Address(es) - (Please provide residential
history and dates for the past five years. Use
additional sheet(s) if necessary.)

12. E-mail Address

15. Sex

13. Driver’s License or State ID Number
(Include State of issuance)

16. Height

17. Weight 18. Eye Color

Feet

Male

Inches

Female

20. Ethnicity
Hispanic or Latino

Yes

(lbs)

No

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21. Race (Please check one or more boxes.)
American Indian or Alaska Native
Black or African American

Native Hawaiian or Other Pacific Islander

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Asian

19. Hair Color

Black
Blue
Brown
Gray
Green
Hazel
Multiple
Pink
Other

White

For the following questions give full details on a separate sheet for all “Yes” answers (See Instructions)
22. Have you ever been a Responsible Person or Employee Possessor for a Federal Explosives Licensee or Permittee? (If known, please
include FEL/P Name and/or Number)

Bald
Black
Blond
Brown
Gray
Red
Sandy
White
Other
Yes

No

23. Will you be or are you an employee of the FEL/P listed in question 1?
24. Will you have actual or constructive possession of explosive materials in the course of your employment? (See Definition 2)
25. Have you ever been issued a letter of denial for your clearance to possess explosives by ATF?
26. Have you ever been granted Explosives Relief from Disability? (If so, please attach a copy of the relief letter.)
27. Are you under indictment or information in any court for a felony, or any other crime, for which the judge could imprison you for
more than one year? Or are you a current member of the military who has been charged with violation(s) of the Uniform Code of
Military Justice, and whose charge(s) have been referred to a general court-martial?
28. Have you ever been convicted in any court, including a military court, for a felony, or any other crime, for which the judge could
have imprisoned you for more than one year, even if you received a shorter sentence, including probation?
29. Are you a fugitive from justice?
30. Are you an unlawful user of or addicted to marijuana, any depressant, stimulant, narcotic drug, and/or any other controlled
substance? Warning: The use or possession of marijuana remains unlawful under Federal law regardless of whether it has
been legalized or decriminalized for medicinal or recreational purposes by state law.
31. Have you ever been adjudicated as a mental defective or committed to a mental institution?
ATF Form 5400.28
Revised November 2023

Yes

No

Yes

No

32. Have you been discharged from the Armed Forces under dishonorable conditions?
33. Country of Citizenship: (Check/List more than one, if applicable. Nationals of the United States may check U.S.A.)
United States of America

Other Country/Countries (specify):

34. Have you ever renounced your United States citizenship? (18 U.S.C. § 842(i)(7))
35. Are you an alien who has been admitted to the United States for permanent residence? (18 U.S.C.§ 842(i)(5)(A))
36. Are you an alien who has been admitted to the United States under a nonimmigrant visa? (18 U.S.C. § 842(i)(5)(B))
37. If you are an alien, record your U.S.-Issued Alien or Admission Number (e.g., AR, USCIS, or I-94 number). Attach supporting documentation to this questionnaire.
(Please note that an employment authorization card insufficient to qualify to serve as an EP.):
38. Under the penalties imposed by 18 U.S.C. §§ 842 and 1001, I declare that I have reviewed the answers on this form and examined any related
documents submitted regarding this questionnaire (ATF Form 5400.28), and to the best of my knowledge and belief, they are true, correct, and
complete. This signature, when presented by a duly authorized representative of the U.S. Department of Justice, will constitute consent and
authority for the appropriate U.S. Department of Justice representative to examine and obtain copies and abstracts of records, and to receive
statements and information regarding my background. Specifically, I hereby authorize the release of the following data or records to ATF: military
information/records pursuant to 18 U.S.C. 842 (i)(6), medical information/records pursuant to 18 U.S.C. § 842(i)(4), police and/or criminal records.

Printed Name

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Signature

Date

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*Note: A copy of this form may be used for your renewal submission (See instruction 2 and 3). I certify, under penalties of perjury, that my answers on
this form are still true, accurate and complete.
Your Signature (For subsequent submission)
Date

ATF Form 5400.28
Revised November 2023

Instructions
1. Who must fill out and complete this form? EACH employee possessor (EP),
as defined below, MUST personally complete the Explosives Employee
Possessor Questionnaire - ATF Form 5400.28, and certify that the answers
are true, accurate, and complete.
2. To whom do I submit this form? You must complete and submit this form
to your employer (applicant for federal explosives license/permit (FEL/P)).
The employer will submit this form on your behalf to ATF for processing. If
this form is being submitted AFTER an FEL/P has been issued to ADD
you as an EP, then the completed form must be accompanied by a signed
letter from the licensee or permittee requesting that you be added as an EP. If this
form is being submitted for at least a second time, in relation to the same FEL/P
renewal, the EP may follow Instruction 3 below, and submit the form to: ATF
National Services Center, Federal Explosives Licensing Center, 244 Needy
Road, Martinsburg, WV 25405.
3. Resubmission of form upon three-year renewal of license/permit. The person
completing the form may choose to resubmit a photocopy of their original ATF
Form 5400.28, provided the information has not changed. You must certify that
all the answers are still true, accurate and complete, by signing and dating the
form.

1. Under Indictment or Information or Convicted in Any Court. An indictment,
information, or conviction in any Federal, State, military, or local court.
2. Employee Possessor (EP). An EP is an individual who has actual or
constructive possession of explosive materials during the course of his
employment. Actual possession exists when a person is in immediate possession
or control of explosive materials (e.g., an employee who physically handles
explosives materials as part of the production process; or an employee, such
as a blaster, who actually uses explosives materials). Constructive possession
exists when an employee lacks direct physical control over explosive materials,
but exercises dominion and control over the explosive materials, either directly or
indirectly through others, (e.g., an employee at a construction site who keeps
keys for magazines in which explosives materials are stored or who directs the
use of explosive materials by other employees; or an employee transporting
explosive materials from a licensee to a purchaser).
3. Alien. An alien in the United States means any person who is not a citizen or
national of the United States.
Exceptions
1. A person who has been convicted of a felony, or any other crime, for which the
judge could have imprisoned the person for more than one year, is not prohibited
from shipping, transporting, possessing, or receiving explosives if: (1) the
conviction was properly invalidated by a court on the basis that the conviction
was unconstitutional; (2) in the case of a Federal conviction, the person received
a Presidential pardon; or (3) ATF granted relief from Federal explosives disabilities
under 18 U.S.C. § 845(b) and 27 C.F.R. § 555.142.

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4. Why is this form required? Title 18, United State Code, Chapter 40, was 		
amended by the Safe Explosives Act of 2002 (the Act). The Act made it
unlawful for certain persons to ship, transport, receive, or possess explosives
materials. The Act also made it unlawful to distribute explosive materials to
certain persons. Information you provide on this form will allow ATF to
determine whether you, an EP in the explosives business or operations, are
prohibited from shipping, transporting, receiving, or possessing explosive
materials. 18 U.S.C. § 842(d), (i).

Definitions
(for additional definitions, please see 27 C.F.R. § 555.11)

5. Should documentation be attached to clarify a response to a question or
item? Providing additional documentation to clarify a response to a specific
question or item on the front of this form could help prevent a delay in
processing your completed ATF Form 5400.28. Please ensure that your name
is on any attached document(s). In addition, if your employer is renewing an
FEL/P ensure that the employer’s current FEL/P number is on any attached
documents.

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6. How do I obtain additional forms? ATF Form 5400.28 can be downloaded
from ATF’s website in Adobe PDF format www.atf.gov/resource-center/formslibrary. The form can be ordered using ATF’s Online Distribution Center Order
Form www.atf.gov/distribution-center-order-form. The form can also be
ordered by calling ATF’s Distribution Center at 240-828-5316.

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7. What do I do if I am prohibited from possessing explosives as indicated
above? If you are prohibited from possessing explosives, you may request relief
from your Federal explosives disability by filing an Application for Restoration
of Explosives Privileges - ATF Form 5400.29. This form can be downloaded
from ATF’s website www.atf.gov/resource-center/forms-library or may be
obtained by calling 240-828-5316. Please be advised that you cannot possess
explosives until that relief from Federal explosives disabilities is granted by ATF.
You may file a relief application, but you cannot possess explosives until such
time that ATF may grant you relief.
8. Need assistance in completing the form? Please review information online
concerning this form at www.atf.gov, Please contact the ATF Explosives
Licensing Center at 877-283-3352, or your local ATF office.
ATF Form 5400.28 is used to determine the eligibility of the EPs to possess
explosives materials. Under Federal explosives laws it is unlawful for certain
prohibited persons to possess explosives. 18 U.S.C. §§ 842(d), (i).
Under 18 U.S.C. § 845(a)(1) these prohibitions do not apply to any “aspects of
transportation of explosives materials via railroad, water, highway, or air
that pertain to safety, including security, and are regulated by the United States
Department of Transportation or the Department of Homeland Security.” The
Department of Transportation and the Transportation Security Adminstration have
exercised their regulatory authority concerning employee qualifications to
transport explosive materials.

2. For purposes of this form, aliens can be EPs if they are lawful permanent
residents. 18 U.S.C. § 842(d)(7); (i)(5).
Privacy Act Information
The following information is provided pursuant to Section 3 of the Privacy Act of
1974 (5 U.S.C. § 552a(e)(3)):
1. Authority. Solicitation of this information is made pursuant to 18 U.S.C. §§ 842 and
843. Disclosure of this information by the EP is mandatory if the EP wishes to
possess explosives.
2. Purpose. The purpose of this collection is to determine the eligibility of the EP
to possess explosives materials.
3. Routine Uses. The information will be used by ATF to make determinations set
forth in paragraph 2. In addition, information may be disclosed to other Federal,
State, foreign, and local law enforcement and regulatory agency personnel to
verify information on the completed ATF Form 5400.28, and to aid in the
performance of their duties with respect to the regulation of explosives unless
such disclosure is prohibited by law. Finally, the information may be disclosed
to members of the public to verify the information on the questionnaire
when such disclosure is not prohibited by law.
4. Effects of Not Supplying the Requested Information. Failure to supply
complete information will delay processing and may cause denial of the application.
5. Disclosure of Social Security Number (SSN). Disclosure of the individual’s
SSN is voluntary. Under 18 U.S.C. §§ 842(f) and 843, and Executive Order
9397, November 22, 1943, ATF has the authority to solicit an individual’s SSN.
The SSN may be used to verify the individual’s identity.
Paperwork Reduction Act Notice
This request is in accordance with the Paperwork Reduction Act of 1995. The purpose of this
information collection is to determine the eligibility of the EP to engage in certain operations.
The information requested is required to obtain or retain a benefit and is mandatory by statute.
18 U.S.C. § 843.
The estimated average burden associated with this collection is 20 minutes per respondent,
depending on individual circumstances. Comments concerning the accuracy of this burden
estimate and suggestions for reducing this burden should be addressed to Report
Management Officer, Resource Management Staff, Contracts and Forms Office, Bureau of
Alcohol, Tobacco, Firearms and Explosives, 99 New York Avenue, NE, Washington, DC
20226.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number.

ATF Form 5400.28
Revised November 2023